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Sick and Afraid, Some Immigrants Forgo Medical Care

Elizabeth, who is in the country illegally, said she has no one to care for her children if she is deported.Credit
Michael Kirby Smith for The New York Times

DURHAM, N.C. — Dr. Luke Smith drove slowly through the unlit streets of a neighborhood filled with immigrants, searching for an address among small houses with windows ribbed by iron bars. Pharmacy bags lay at his feet.

His mission: to deliver medication to patients too frightened to pick up their prescriptions.

On this evening, Dr. Smith, a psychiatrist, was looking for the family of a 12-year-old boy with attention deficit disorder. Like most people who have sneaked into the United States illegally, the boy’s parents, from Puebla, Mexico, do not have drivers’ licenses.

Now, when they drive, being stopped at one of the frequent traffic checkpoints here can have consequences far more costly than a fine. Shaken by the Trump administration’s broad deportation orders, they and many others like them are retreating into the shadows, forgoing screenings, medications and other essential medical care.

Several times a week, Dr. Smith picks up prescriptions at pharmacies, then meets patients at their homes to hand them the medications they require.

José and Irma’s two children, who are U.S. citizens.Credit
Michael Kirby Smith for The New York Times

Across the country, from Venice, Calif., to Brooklyn, clinics that serve an immigrant population report a downturn in appointments since the administration’s crackdown. In a recent national poll of providers by Migrant Clinicians Network, which is based in Austin, Tex., two-thirds of respondents said they had seen a reluctance among patients to seek health care.

Some parents have been withdrawing children from federal nutrition programs to avoid scrutiny. In Baltimore, health care workers who have for years visited Latino neighborhoods to test people for sexually transmitted infections now wait in vans outside 7-Elevens and Home Depots.

Experts say the toll for avoiding the health care system is far-reaching. Poorer Latinos, in particular, suffer from high rates of obesity, diabetes, liver disease and high blood pressure. “Patients who are already sick will have a much harder time getting better,” Dr. Page said. Those who don’t get care for infectious diseases, she said, “are much more likely to transmit infections to others.”

Yet as medical costs present a burden for millions of Americans, many people question why citizens who can scarcely afford their own health care should support through taxes the care of those living here illegally.

One provider surveyed in the Migrant Clinicians Network poll wrote: “There has been a fair amount of animosity towards me for helping the workers. Locals think that the workers are receiving grand benefits.”

Here in central North Carolina, where immigrants work in tobacco fields and chicken-processing factories, and wash dishes and clean bathrooms in booming downtown restaurants and hotels, some health care providers are going to unusual lengths for patients.

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Dr. Luke Smith delivering medication to a woman in the country illegally in Greensboro, N.C.Credit
Michael Kirby Smith for The New York Times

Dr. Smith walked onto a dark porch and knocked on a door. “Está Jorgito?” he called out.

Eyes peered out through slats of a lowered blind. Jorgito, a taco truck owner, flung open the door and rushed forward, beaming.

In the crowded front room, Jorgito, who, like other illegal immigrants interviewed for this article, asked that his last name be withheld to prevent officials from identifying him and his family, introduced the doctor to his friends, relatives and pastor.

Only after the family had urged him to sample some homemade, thick Central American-style tortillas, did Dr. Smith discreetly hand Jorgito the medication for his son, a bashful sixth grader lolling on a couch.

This fall, when Dr. Smith met the boy’s parents at school and told them that medication could help their distracted, failing son, the father was standoffish and suspicious. But since then, the boy’s diligence, grades and self-esteem have improved — and so has Jorgito’s confidence in Dr. Smith.

Despite the family’s entreaties to stay, Dr. Smith begged off. It was nearly 10 o’clock. Another family was waiting for medicine.

Shattered Trust

Except for absolute necessities, Rodolfo, an itinerant construction worker who entered the United States illegally from Puebla six years ago, does not leave his house these days.

But for a month now, his 8-year-old daughter, Leslie, has been doubling over in pain after meals. So, uneasily, on buses and on foot, Rodolfo took her to the community health clinic in Carrboro, a liberal, well-heeled town just west of Chapel Hill.

In the exam room, the child shrank into herself, stiff and uncomfortable. Lisanna Gonzalez, a family nurse practitioner, could find no physical cause for her discomfort.

Eventually Leslie admitted she was terrified that she would come home from school one day and find her parents gone. Kids were always talking about it, she said, even teasing her. Her brother, 13, kept showing her social media updates about raids.

Fear is making people sick, said Dr. Evan Ashkin, a professor of family medicine at the University of North Carolina who directs a residency program for doctors who work with poor patients.

Providers, he explained, have seen an increase in common physical manifestations of depression and anxiety: stomach aches, blurred vision, dizziness, insomnia, headaches, spikes in blood pressure, shortness of breath.

“I understand why you’re worried, and I hope nothing like that will happen,” Ms. Gonzalez told Leslie and her father, in Spanish. “We can’t take away the stress, but we can give you some ways to to manage the anxiety.”

A dishwasher in Durham who has been in the country illegally for six months.Credit
Michael Kirby Smith for The New York Times

She handed Rodolfo a checklist, assembled by the Immigrant Legal Resource Center, on how to prepare for a possible deportation: Decide who can care for your children. Write down their medications and important phone numbers. Tell your family whom to call if you are detained.

Providers at these federally qualified health centers, which receive some government funds to serve the uninsured and underinsured, do not ask patients about their citizenship status. Instead, the patients, who are required to pay a modest clinic fee, must show proof of residence and income.

For decades, these clinics have been safe havens. When police officers parked in the Carrboro clinic’s lot for a coffee break, a doctor chased them off because she didn’t want patients to be frightened.

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Now some insulin-dependent patients have been no-shows at appointments. Diabetes patients, who must exercise, have told doctors here they will not even walk around the block, skittish about the cruising police cars — even though a few departments have announced they will not check immigration status.

Dr. Ashkin has built up relationships with many uninsured immigrants over the years. But recently a longtime patient, pregnant but having first-trimester bleeding, refused to take his advice to go for an ultrasound at the university medical center at Chapel Hill.

She was fearful that immigration agents might be waiting. Fortunately, the bleeding stopped.

Referring to the dread among his patients, Dr. Ashkin said, “Their trust in us is breaking down.”

This is not the first time that fear has kept undocumented patients away. Researchers found that in the wake of expanded immigration enforcement in Arizona in 2010, illegal immigrants used health services less frequently, according to a study published in The American Journal of Public Health.

After a large federal immigration raid in 2008 in Postville, Iowa, babies born to Latinas had a 24 percent higher risk of low birth weight than those born a year earlier, according to a study published this year in The International Journal of Epidemiology.

The effects of deferred health care will be felt in many ways, experts said. Hospitals and emergency departments, exponentially more expensive than primary care, will treat more sick patients, said Dr. Joshua M. Sharfstein of the Johns Hopkins Bloomberg School of Public Health. School systems will feel the impact of more students with a range of health-related challenges.

Researchers have also looked at the question of federal benefits for illegal immigrants.

Many are paid off the books in cash. But certainly not all. Between 2000 and 2011, immigrants not authorized to work here contributed between $2.2 billion and $3.8 billion a year more to Medicare than they withdrew, according to a 2016 study.

José, 42, works year-round for a tobacco grower; his wife, Irma, 44, picks tobacco and also works at a local steakhouse, wiping down tables and mopping floors. They do not have Social Security numbers because they are here illegally.

“But we pay taxes!” Irma declared, responding to the argument that taxpayer-funded clinics should serve only legal citizens.

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Dr. Evan Ashkin at work at the Prospect Hill Community Health Center.Credit
Michael Kirby Smith for The New York Times

Their paycheck deductions are taken with individual tax identification numbers. But, she noted, neither is eligible for the programs those taxes fund, including Social Security, Medicare and Medicaid.

Post-Traumatic Stress Flares Up

Siler City is a town of about 8,000 an hour southwest of Durham. The road there runs past tobacco fields, a derelict former chicken-processing factory and trailer parks into a downtown lined with storefront Pentecostal churches. A sign in an art gallery window warns: No Weapons Allowed.

In a ranch house with chipped gray-blue siding is a branch of El Futuro, Dr. Smith’s mental health clinic. Post-traumatic stress disorder is prevalent among patients, said Karla Siu, the clinical program director.

A 9-year-old recalls sleeping in the desert, awakening to a snake. Women quake from memories of being raped on the road. Men seethe, mortified, less from having been stiffed of a day’s wages than from being too afraid to file a complaint.

As stories of raids churn through rumor mills, therapy sessions have become especially tense. Clinicians report that some patients conclude sessions with ever more elaborate farewells.

“The client is grieving the possibility of not seeing the therapist again,” Ms. Siu said. “So saying goodbye with hugs and tears each time is a form of control, because it’s on their own terms.”

El Futuro has waiting lists of people who want help. But in a survey of patients, the clinic found that some people are afraid to come in. Elizabeth, 27 and here illegally, is among them.

With great reluctance she showed up at the clinic for an interview with a reporter, arriving late, uneasy. Apologizing, she said she leaves her apartment these days only to go to the grocery store and to her job as a hotel maid.

She has no one who will care for her two young children if she is deported, she explained haltingly, tears welling up.

And in Mexico, another danger awaits: her ex-boyfriend. Years ago, when the couple arrived in North Carolina, she said, he began to beat her so badly that she finally called the police. They arrested him and had him deported.

Now, fearful for her children and for her own safety, Elizabeth is consumed by anxiety. Her nightmares from that violent period are back.

After recounting her story, Elizabeth walked toward El Futuro’s reception area, clutching her 5-year-old daughter’s hand. Even if she cleared the clinic’s wait list, she said, it just seemed too risky to come back.